Veterans Home of California - Yountville - SNF

In the surveyor’s words

From the most serious findings on record at Veterans Home of California - Yountville - SNF, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 5, 2023

  Based on interview and record review, the facility failed to keep one of three residents (Resident 1) free from neglect when the facility did not use the recommended Hoyer Lift (a transfer device) on 5/9/22 to transfer Resident 1 from the bed to his wheelchair. This failure resulted in Resident 1 sustaining a fracture to his right knee that required hospitalization . Findings: During a review of Residents 1's Interdisciplinary Progress Notes (IDN), dated 5/9/22, the IDN indicated Certified Nursing Assistant (CNA) 1 lifted Resident 1 and tried to transfer Resident 1 from his bed to his wheelchair with the help of CNA 2. Resident 1 informed the CNAs that his legs were going out. According to the IDN, Resident 1's legs got limp. […]

• Actual harm, isolatedF636Jul 5, 2023

  Based on interviews and record review, the facility failed to update a care plan for one of three residents (Resident 1) for the use of a Hoyer Lift (a lift used for dependent residents requiring two caregivers to facilitate safe patient transfers) the recommended device by Physical Therapy (PT) and the Interdisciplinary Team (IDT). This failure resulted in a traumatic injury, of a right knee fracture for Resident 1. Findings: During a review of Resident 1's List Patient Notes, dated 3/11/21, the form indicated the last Physical Therapy Assessment was completed on 3/11/21. The form indicated Resident 1 was dependent for all mobility needs and a Hoyer lift was recommended to be used to get Resident 1 out of bed and into Resident's 1 manual wheelchair. […]

• Actual harm, isolatedF689Jul 5, 2023

  Based on interview and record review, the facility failed to keep one of three residents (Resident 1) free from accidents on 5/9/22 when facility staff attempted to transfer Resident 1 from his bed in a [NAME] Flex Lift (a lift support aid which encourages residents to pull themselves up into a standing position) to his wheelchair in place of the Hoyer Lift (a lift used for dependent residents requiring two caregivers to facilitate safe patient transfers). The recommended device by Physical Therapy (PT) and the Interdisciplinary Team (IDT) was the Hoyer Lift. […]

• No harm, potential for more than minimal, widespreadF812Mar 26, 2026

  Based on observation, interviews, and record review, the facility failed to ensure that food safety and sanitation guidelines were followed when multiple expired food items were found in the dry storage and refrigerator of the main and satellite kitchen. These failures posed the risk for food-borne illnesses (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 162.Findings: During a concurrent observation and interview on 3/23/26 at 2:01 PM in the Main Kitchen- G07 Refrigerator with the Food Manager (FM) 1, one large tray labeled Orzo Pasta had an expiration date of 3/11/26. […]

• No harm, potential for more than minimal, widespreadF801Mar 7, 2025

  Based on interview and record review, the facility failed to ensure there was a designated full-time qualified person who met the qualifications specified in established State statute (California Code, Health and Safety Code - HSC § 1265.4) for food service managers, to carry out the functions of food and nutrition services (FNS) for the licensed care facility. The failure to have qualified day-to-day oversight of FNS elevated the risk of dietetic services not being carried out in accordance with professional standards for food service safety placing 144 residents, who received food from the kitchen at risk for potential food related medical complications. […]